Results-based financing and NCDs€¦ · Life Lost in the Caribbean due to NCD (global avg. 50%)...
Transcript of Results-based financing and NCDs€¦ · Life Lost in the Caribbean due to NCD (global avg. 50%)...
Carla PantanaliHealth, Nutrition and Population
Results-based financing and NCDs An overview of the WB work in the
Caribbean
Why RBF forNCDs in theCaribbean?
What are we doing?
Design issuesand
challenges
Outline of the presentation
Health challenges in emerging markets…
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
do not vary significantly…
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
and the Caribbean is no exception
Rise in non-communicable disease burdenFinancial burden is increasing and will
increase more Spending in health is relatively low and
not optimally allocatedShortage of trained medical and nursing
staff
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
Some data to keep in mind…Burden of Disease:around 70% of Years ofLife Lost in theCaribbean due to NCD(global avg. 50%)
High Expenditure. NCDpatients spend 36% oftotal householdexpenditure for care
Erosion of the countries’workforce and productivityand increase vulnerabilitiesof the Caribbeanpopulation
Heavy burden on limited resources for both governments and
households
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
Substantial BOD due to NCDs in the Caribbean
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
-Overweight/Obesity 38.4% males, 65.3% females to be obeseby 2015.
-Excessive alcohol consumption common across the Caribbeanand in poorer households
-Physical Inactivity levels due to urbanization and sedentarylifestyles
-Smoking responsible for at least 10% of all deaths in theCaribbean.
Risk factors have worsened…1Why RBF for
NCDs in theCaribbean? 2What are we
doing? 3Design and challenges
Lost output due to the five conditions
≈ US$ 47 trillion
In low and middle incomecountries cumulative economiclosses in the period 2011-2025are estimated to surpassnearly US$ 7 trillion.
That means…— Average of nearly US$ 500
billion per year
— Yearly loss equivalent toapproximately 4% of thesecountries’ current annualoutput
16 trillion
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
Projections get worse…
Source: Harvard School of Public Health
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
2012 2014
WHAT HAVE WE DONE SO FAR IN THE CARIBBEAN?
BOD Saint Lucia 1990/2010
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
BOD Dominica 1990/20101Why RBF for
NCDs in theCaribbean? 2What are we
doing? 3Design and challenges
CONVENING
RBF:
S2S Exchanges to
Pilot RBF to address
NCDs
NCD: Dominica and Saint
Lucia situational
analysis
ASSESSMENT FINANCING
Potential
Regional
Operation for
NCDs
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
2012 2014
Situational analysis in Saint
Lucia and Dominica
Recommendations for Piloting RBF
approaches in the Dominica and
Saint Lucia health sector
Financing for piloting RBF for NCDs in SL and
Dom
PILOT IN SAINT
LUCIA AND
DOMINICA
Phase 1: ASSESSMENT
Jan 2012: RBFawareness raisingworkshop
Nov 2012: In-countryconsultation
Expectations!
Analysis offinancing options
Assessment oforganizationalarrangements andHIS and M&E
In-countrydiscussion ofresults
Securing of WB TFfor piloting RBF
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
ARGENTINA
(NOV 2013)
DOMINICAN REPUBLIC
(JAN 2014)
BELIZE (FEB2014)
PILOT IN SAINT
LUCIA AND
DOMINICA
Phase 2: Knowledge exchanges
FESP Project Plan Nacer Fiduciary
arrangements(audit)
Pay-for-performancescheme
PARS 2Project
Informationsystem
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
Strengthen the stewardship of National and Provincial Authorities
Reduce exposure of population to risk factors associated to NCDs
Expand coverage of 7 Groups of Diseases and Prioritized PublicHealth diseases
Strengthen Health Promotion, Healthy habits and lifestyles and community participation
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1
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges ARGENTINA
3
4
How they use RBF ?
Essential Public Health Functions Project
• Group of actions aimed at strengthening and improving publichealth results
• Effective and standardized activities, with measurable andjustifiable value.
• At design:
Identify operational unit costs of delivering PHAs
• At implementation:
Identify and agree on annual targets to be achievedDefine protocols for each PHA and for the External Audit
PUBLIC HEALTH ACTIVITIES - WHAT ARE THEY?
ARGENTINA 1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
Safe Blood Program : Increase voluntary blood donations
How the Project tracks the indicator:
1) Traditional Financing: Construction of a regional blood banks
2) Eligible Medical Supplies: Procurement of reagents to screen blood
3) RBF - PHA:- Blood donation operatives by regional blood banks (25 donors) - Unit of measurement: # of operatives - Unit cost components: professionals and technicians extra time, travel
and meals, promotion materials, data collection - Unit cost: UDS 870
ARGENTINA 1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
LIFE CYCLE OF PHAs
ARGENTINA 1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
Partnerships with the Argentina Association of Bakeries towards
salt reduction
7,000 out of 28,000
bakeries engaged in
salt reduction strategy
ARGENTINA
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
• Improve need for strategic planning
• Collaborate with progress of identification ofpopulation
• Foster allocative efficiency
• Improve data quality
• Introduce reimbursement on the bases ofpublic health results
WHY PHAs?
ARGENTINA 1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
Before
Plan Nacer
• Implicit universal public coverage.
• Financed through public budget.
• Quality and coverage gaps.
Plan Nacer
• Explicit coverage of prioritized services for the population without formal insurance.
• Additional investment through RBF
• Quality driven strategy.
Final Objetives
Improve the healthstatus of population
Increase
satisfaction
ARGENTINA 1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
NATION
Sets a per
capita value
USD2,5
PROVINCE
Health outcomes –
Tracer indicators
(every four months)
Enrollment
(monthly payment)
Provincial
Health Insurance
HEALTH PROVIDER
Fee for
Service
(monthly payment)
StewardshipAutonomy in use of funds
Consensus
Full Capitation payment based on performance
USE OF FUNDS•Staff Incentives•Staff hiring and
training•Supplies•Investment•Maintenance
Performance Agreement
EXTERNAL and INTERNAL VERIFICATION
Virtuous cycle promoted by the Program
Health care is provided to the
population
Health professionals
complete the medical records
Administrative staff
bill the health services
Additional resources
to health providers
Verification and Payment
Tracers measurement
Improvements in health care
Ex post Verification
RBF thru Health Sector Reform Project
Supports GODR overall goal: improve quality of health expenditures & health services
Primary Health Care focus
Performance based contracts between MOH and Regions, in coordination with NHI
50% = capitation for essential health services package
50% = regional performance for 10 indicators (MCH & comm. diseases; NCDs) of coverage & quality
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DOMINICAN REPUBLIC 1Why RBF for
NCDs in theCaribbean? 2What are we
doing? 3Design and challenges
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DOMINICAN REPUBLIC
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
Fosters results-oriented & learning culture
Improvements: data recording & info verificationsystems/mechanisms
RBF regions account for ~ 81% of Clinical Mgt. System (CMS)entries nationwide
Notable progress in indicators (2011 to 2013) % children < than 15 mos. w/ complete vaccination scheme acc. to protocols: 0.01
to 46.7
% of pregnant women monitored for risk acc. to protocols: 0.43 to 18.8
% of children monitored for growth & devt. acc. to protocols: 0.27 to 25.8
% of individuals > 18 years w/ hypertension screening acc. to protocols: 0.89 to 45.2
DECIDE
What to reward
Who to reward
How much to reward
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
Phase 3: Designing the pilot
AFTER ASSESSMENT….DECIDE!
Strategies for Prevention and Control of NCDs
Focus: DIABETES and HYPERTENSION
Public Health
Interventions
Surveillance
Health Facilities
Institutional Strengthening
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
Assessment of existing tools, guides & protocols
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
Paying for
inputs
Paying for
outputs
Paying for performance
Paying for outcomes/
results
• Line item budgets
• Fee-for-service
• Fee-for-service
• DRG
• Capitation
P4P
• Mixed models
Full capitation with performance incentives
Episode-based payment with performance incentives
Provider payment models
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1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
2 proposed Components for RBF pilotfor NCDs for Saint Lucia and Dominica:
1) Output Based Disbursement(PHA or P4P)
2) Capitation
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
1) Output Based Disbursement
Payments for Public Health Activities ona production basis
Payment = Costs of activities * quantityof activities
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
=
Base Per
Capita Rate
X
# of People
Enrolled with that Provider
Adjustments
X
Fixed payment to a Provider to
Deliver all Services in a
Defined Package for one
Individual for a Fixed Period of
Time Patients are linked to a provider for a fixed period of time 34
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges 2) Capitation
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
Chief HealthPlanner (CHP)
ClinicsMinistry of
Health (MOH)
• Define Protocols
• Budget allocation
• Establish goals
• M & E
• Determine allocation to clinics
• Enroll target population
• Provide services
• Report clinicrecords
• Allocate funds
Who are the stakeholders involved?
DECISIONS TO MAKE:
PE = number of target population enrolled
K = Capita
GA = Percentage of GoalsAccomplished
Decision 1: Population to cover
Decision 2: Amount of theCapita. Significant enoughto change behaviour
Decision 3: Type of indicators
Allocation of fundsDecision 4: Definition of elegible items
SF = 30% * (K *PE ) + 70% *(K * PE * GA)
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
TO KEEP IN MIND….
CLEARLY DEFINE THE GOAL OF THE PROJECT : Standardization of care or Reduction of Incidence of Diabetes and Hypertension?
Do we want to improve the quality of life through the effective management of Diabetes Mellitus & Hypertension?
Or Improve the effective standardization of care in theapproach to the management of NCDs and the reduction of theincidence and complications among the population?
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
CHOOSE YOUR TARGET POPULATION for each specific intervention
Indicators: Need to be measurable and attainable within the project timeframe. If using PHAs, align them with result indicators
Given the importance of quality assurance, consider selectinginitial indicators that would focus on updating of and training onprotocols and dedicating HR to enforce compliance
PHA: Need to develop guidelines and protocols for each PHA aswell as information systems for record-keeping
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges
IMPLEMENTATION ARRANGEMENTS: ASSESS RBF IMPACT AT THESYSTEM LEVEL
-Decentralized system in Dominica will require fundingfor RBF allocated to the districts and managed at that level.
-Centralized system in Saint Lucia: few organizationalchanges due to RBF. The MOH will remain the payer ofservices through the Primary Health Care Services.
HUMAN RESOURCES: RBF scheme may result in a redistribution of personnel
1Why RBF forNCDs in theCaribbean? 2What are we
doing? 3Design and challenges